Health Care Access, Quality, and Outcomes among Individuals with Dementia in Dual Eligible Special Needs Plans

Addressing the long-term care needs of a growing number of older individuals with Alzheimer's disease and related dementias (AD/ADRD) is one of the most daunting challenges facing the U.S. public health safety net. AD/ADRD is one of the most expensive categories of chronic conditions in the U.S. Older adults with AD/ADRDs

have complex long-term care needs for medical, behavioral, and social supports. Medicaid is the public program that is chiefly responsible for paying the costs of long-term care supports and services (LTSS) for older adults with AD/ADRD who have exhausted their resources and ability to pay for needed long-term care. A growing

trend in Medicaid programs has been to support older individuals with AD/ADRD at home rather than in nursing homes by offering Medicaid enrollees greater access to Home and Community Based Services (HCBS) services, such as in-home personal care services and case management. The rapid rise of Medicaid HCBS and home-

based AD/ADRD care has served to highlight a growing problem of lack of coordination of Medicaid HCBS and other needed chronic care management services by duals’ primary health insurance carrier, which is Medicare. The long-term goal of this project is to provide an evidence base for viable solutions to this Medicare-Medicaid

coordination problem. Medicare Advantage (MA) Dual Eligible Special Needs Plans (D-SNPs) are private managed care plans that only enroll dual eligible individuals. A special type of integrated D-SNP that combines Medicare Advantage and Medicaid benefits under one managed care provider may result in better care

coordination, longer community tenure, less nursing home use, and improved health outcomes among older disadvantaged individuals with AD/ADRD. This project uses nationwide linked Medicare-Medicaid administrative data to compare the effectiveness of integrated D-SNPs to non-integrated D-SNPs among duals with AD/ADRD

based on the results of three analyses. The first analysis compares HBCS use among duals with AD/ADRD in integrated and non-integrated D-SNPs; the second analysis compares in-home service and prescription drug process quality indicators among duals with AD/ADRD in integrated and non-integrated D-SNPs; and the third

analysis compares nursing home use, community tenure, and plan disenrollment among duals with AD/ADRD in integrated and non-integrated D-SNPs. This project uses linked Medicare and Medicaid managed care encounter data from the years 2021-2023. The final project dataset will contain over 150,000-year-quarter

observations on D-SNP enrollees from over 250 unique D-SNPs. This project will be among the first to comprehensively describe both Medicaid and Medicare service use among duals with AD/ADRD. With assistance from project partners, the results will be disseminated to a broad stakeholder audience of Medicaid

officials, the Centers for Medicare and Medicaid Services (CMS), and policy advocates for individuals with AD/ADRD conditions.